Failure to Maintain Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents. For one resident, the records showed that a Fentanyl patch was applied on multiple dates, but there was no documented evidence that the old patches were destroyed as required. This lack of documentation was confirmed by the Nursing Home Administrator during an interview. Another resident had orders for Oxycodone/Tylenol to be administered as needed, but the medication administration record did not show evidence of administration on several dates when the controlled drug record indicated it was signed out. Similarly, a third resident had orders for Percocet, but the medication administration record did not reflect administration on dates when the controlled drug record showed it was signed out. The Nursing Home Administrator confirmed the absence of documentation for the administration of these medications. These findings indicate a failure in maintaining accurate records and accountability for controlled substances, as required by the regulations.
Plan Of Correction
Residents 28 and 36 were noted to not have any adverse effects from not having documented medication administration in the electronic medical record (EMR). Resident 4 was noted to not have any adverse effects from not having documentation of destroyed controlled substances. A facility-wide sweep of all residents in-house with the physician order of Percocet was conducted to ensure all administrations were documented in the narcotic book and matched the EMR. A facility-wide sweep of all residents with Fentanyl patches had documentation of medication destruction upon removal on the narcotic (NARC) signoff sheet. All licensed nurses were educated on medication administration and documentation in the EMR, as well as the destruction of controlled substances. The Director of Nursing or designee will conduct audits to ensure that all Percocet administrations are documented in the narcotic book and match the EMR, and that Fentanyl patches have documentation of medication destruction upon removal on the NARC sheet weekly for 4 weeks and monthly for 2 months. Identified issues are addressed at the time of discovery. Audit results are reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education/re-education.